Disability Benefits Questionnaires (Group 4)

Forms and Documents

Document Name	Status
Form VA Form 21-0960C-3 Disability Benefits Questionnaires (Group 4) Form	Modified
Supporting Statement (2900-0781).docx Supporting Statement A	2019-09-30
2019-16024.pdf Supplementary Document	2019-08-06
2019-09203.pdf Supplementary Document	2019-05-07

IC Document Collections

IC ID	Document Title	Status
196008	Disability Benefits Questionnaires (Group 4) Form	Modified

ICR Details

OMB Control No: 2900-0781	ICR Reference No: 201903-2900-012
Status: Historical Active	Previous ICR Reference No: 201511-2900-002
Agency/Subagency: VA	Agency Tracking No: VBA-COMP-NK
Title: Disability Benefits Questionnaires (Group 4)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/23/2019
	Date Received in OIRA: 10/01/2019
Terms of Clearance: VBA shall review the forms in this collection to determine if they are voluntary or required to obtain and retain a benefit and ensure that in the next revision or extension request that this information is correct in the Privacy statement and consistent across the forms in this collection. VBA shall also ensure that such information is in plain language.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2022	36 Months From Approved	12/31/2019
Responses	160,000	0	160,000
Time Burden (Hours)	53,750	0	53,750
Cost Burden (Dollars)	0	0	0

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Abstract: Group 4 (DBQs) are used to assist veteran's who require a disability examination in support of a claim for VA benefits. These forms are used to record the findings of the examining physician.

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Authorizing Statute(s): US Code: 38 USC 501(a) Name of Law: Rules and Regulations
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 9203	05/06/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 16024	07/29/2019
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Disability Benefits Questionnaires (Group 4)	VA Form 21-0960I-4, VA Form 21-0960D-1, VA Form 21-0960E-2, VA Form 21-0960E-3, VA Form 21-0960H-1, VA Form 21-0960I-3, VA Form 21-0960I-5, VA Form 21-0960L-1, VA Form 21-0960Q-1, VA Form 21-0960J-4, VA Form 21-0960N-3, VA Form 21-0960N-4, VA Form 21-0960C-3, VA Form 21-0960C-6, VA Form 21-0960C-7, VA Form 21-0960C-11, VA Form 21-0960I-2	Cranial Nerves Diseases Disability Benefits Questionnaire ,   Narcolepsy Disability Benefits Questionnaire ,   Fibromyalgia Disability Benefits Questionnaire ,   Seizure Disorders (Epilepsy) Disability Benefits Questionnaire ,   Hernias (Including Abdominal, Inguinal and Femoral Hernias) Disability Benefits Questionnaire ,   HIV-Related Illnesses Disability Benefits Questionnaire ,   Infectious Diseases (Other than HIV-Related Illness, Chronic Fatigue Syndrome, or Tuberculosis) Disability Benefits Questionnaire ,   Systemic Lupus Erythematosus (SLE) and Other Autoimmune Diseases Disability Benefits Questionnaire ,   Nutritional Deficiencies Disability Benefits Questionnaire ,   Oral and Dental Conditions Including Mouth, Lips and Tongue (Other than Temporomandibular Joint Conditions) Disability Benefits Questionnaire ,   Endocrine Diseases (Other than Thyroid, Parathyroid or Diabetes Mellitus) Disability Benefits Questionnaire ,   Thyroid and Parathyroid Conditions ,   Urinary Tract (Including Bladder and Urethra Conditions) (Excluding Male Reproductive System Disability Benefits Questionnaire ,   Respiratory Conditions (Other than Tuberculosis and Sleep Apnea) Disability Benefits Questionnaire ,   Loss of Sense of Smell and/or Taste Disability Benefits Questionnaire ,   Sinusitis/Rhinitis and Other Conditions of the Nose, Throat, Larynx and Pharynx Disability Benefits Questionnaire ,   Chronic Fatigue Syndrome Disability Benefits Questionnaire

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	160,000	160,000	0	0	0	0
Annual Time Burden (Hours)	53,750	53,750	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $14,348,071

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/01/2019

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